Sustainable Approaches to Medical Tourism: Strategies for Central Macedonia/Greece

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This paper sets out a very ambitious purpose in wishing "to gain a better comprehension of the concepts of medical tourism, health, and wellness tourism, as well as to explore 49 strategies for developing tourism in the Region of Central Macedonia." Yet it starts by making an erronous claim, namely "Health and wellness tourism, commonly referred to as medical tourism". Health tourism is the umbrella that encapsulates medical, wellness and spa tourism. See for instance the graphical representation in  Hall, C. M. (2011). Health and medical tourism: a kill or cure for global public health?. Tourism review, 66(1/2), 4-15 or in  the works by Smith, M., & Puczkó, L.  It would be far better to focus in on medical tourism and not get side-tracked by the other forms of health tourism that are not relevant to this paper.

The authors repeatedly refer to sustainability, "sustainable medical tourism services" and "green health packages" with insufficient explanation. Similarly, the list of "sustainability factors"  (cost savings, advanced healthcare, cutting-edge technology, innovative treatments, modern medical equipment, enhanced hospitality, personalized care, and the offer of different quality versions of the product) is thrown out without being explored or justified. At the same time, the biggest criticism of medical tourism is that scarce resources are going for the economic benefits to be derived by the public and private sectors while the resident population receives insufficient care. Yet the authors do not address this at all, if only to document that residents are not short-changed. Similarly, medical treatments generate a significant amount of quite toxic waste but no mention is made of how this will or could be addressed in the context of Central Macedonia. There is far too much focus on the economic sphere of sustainability only. 

 

Another lofty ambition of this research is "to make a significant contribution to further research in the realm of medical tourism policy-making, transnational healthcare, domestic and international patient mobility, addressing healthcare disparities, the business of medical travel, the geography of medical tourism, and travel medicine." It would be far better to reduce these ambitions and stay more focused on the real contributions of this research. In particular the theoretical contributions are rather contrived and/or not achieved, e.g. the integration of sustainability into medical tourism theories or the linking of healthcare and environmental management theories. 

 

There is far too much detail, especially regarding the questionnaire results, to make this paper readable. Consideration should be given to moving some of this information into appendices and just providing a summary of those findings in the main text. Also, there is no mention of the findings of the Systematic Literature Review nor is there any concrete evidence provided on the current state of health and wellness tourism at national and international levels. The methodology deals largely with the questionnaire but without informing the reader about the participants, the logistics of data collection, the source of items (what are diplomatic surveys?), etc.  

 

Comments on the Quality of English Language

This reads like a typical consultant study and an extract at that since the aims listed are far broader than what is discussed here. At the same time, the reader is overwhelmed by tables that have minimal interpretation. At the very least this paper requires a major overhaul and a much more focused approach.

Author Response

Dear Reviewer 1,

Thank you for providing feedback and granting us the opportunity to publish this article. We have meticulously incorporated your valuable advice into the revised version, with all modifications prominently highlighted in yellow in the revised article. To summarize, the key adjustments made are as follows:

1) Title was changed to include the term 'sustainable'.

2) Tables 8-17 were eliminated, and the text was modified to enhance the article's readability.

3) Research Questions were reformulated and a justification for their selection was made.

4) In order to clarify issues of research methodology, the following chapters have been added to the article

3.3.1. Systematic Literature Review

3.5. Conducting the Quantitative Research

3.6. Analysis of Survey Data

3.7. Reliability and Validity of Research Instrument

5.2. Interconnection between Sustainable Development Goals (SDGs) and SWOT Analysis

5.2.1. Sustainable factors in the context of medical tourism within Central Macedonia / Greece

5.2.2. Negative impact of medical tourism on locals, the environment and SDG’s.

Our responses to your comments are presented in detail below:

 

This paper sets out a very ambitious purpose in wishing "to gain a better comprehension of the concepts of medical tourism, health, and wellness tourism, as well as to explore 49 strategies for developing tourism in the Region of Central Macedonia." Yet it starts by making an erronous claim, namely "Health and wellness tourism, commonly referred to as medical tourism". Health tourism is the umbrella that encapsulates medical, wellness and spa tourism. See for instance the graphical representation in  Hall, C. M. (2011). Health and medical tourism: a kill or cure for global public health?. Tourism review, 66(1/2), 4-15 or in  the works by Smith, M., & Puczkó, L.  It would be far better to focus in on medical tourism and not get side-tracked by the other forms of health tourism that are not relevant to this paper.

Comment 1: As a reply, we propose this opinion of Hall 2011: ‘Health and medical tourism is a complex area of study… Such research must include contributions not only from medical and health research but also from tourism studies’. (Hall CM. Health and medical tourism: a kill or cure for global public health?. Tourism review. 2011 May 10;66(1/2):4-15.). We have included this reference in the new version of our paper.

The authors repeatedly refer to sustainability, "sustainable medical tourism services" and "green health packages" with insufficient explanation. Similarly, the list of "sustainability factors"  (cost savings, advanced healthcare, cutting-edge technology, innovative treatments, modern medical equipment, enhanced hospitality, personalized care, and the offer of different quality versions of the product) is thrown out without being explored or justified. At the same time, the biggest criticism of medical tourism is that scarce resources are going for the economic benefits to be derived by the public and private sectors while the resident population receives insufficient care. Yet the authors do not address this at all, if only to document that residents are not short-changed. Similarly, medical treatments generate a significant amount of quite toxic waste but no mention is made of how this will or could be addressed in the context of Central Macedonia. There is far too much focus on the economic sphere of sustainability only. 

Comment 2: please see new title (Title was changed to include the term 'sustainable') and new chapterL 5.2.2. Negative impact of medical tourism on locals, the environment and SDG’s.

 

Another lofty ambition of this research is "to make a significant contribution to further research in the realm of medical tourism policy-making, transnational healthcare, domestic and international patient mobility, addressing healthcare disparities, the business of medical travel, the geography of medical tourism, and travel medicine." It would be far better to reduce these ambitions and stay more focused on the real contributions of this research. In particular the theoretical contributions are rather contrived and/or not achieved, e.g. the integration of sustainability into medical tourism theories or the linking of healthcare and environmental management theories. 

Comment 3: We scaled back our aspirations, and the adjustments made align with your recommendations, altering both the ambitions and theoretical contributions.

 

There is far too much detail, especially regarding the questionnaire results, to make this paper readable. Consideration should be given to moving some of this information into appendices and just providing a summary of those findings in the main text. Also, there is no mention of the findings of the Systematic Literature Review nor is there any concrete evidence provided on the current state of health and wellness tourism at national and international levels. The methodology deals largely with the questionnaire but without informing the reader about the participants, the logistics of data collection, the source of items (what are diplomatic surveys?), etc.  

Comment 4: Tables 8-17 were eliminated, and the text was modified to enhance the article's readability. Moreover, the methodology and the findings of the Systematic Literature Review (SLR) underwent modifications in accordance with your recommendations.( The term "diplomatic surveys" was a typographical error, and it has already been rectified).

 

English Language:

This reads like a typical consultant study and an extract at that since the aims listed are far broader than what is discussed here. At the same time, the reader is overwhelmed by tables that have minimal interpretation. At the very least this paper requires a major overhaul and a much more focused approach.

Comment 5: please see comment 4, about Tables. Numerous adjustments have been implemented concerning the English language.

 

In any case we have highlighted all alterations in the revised paper with the color yellow.

 

We appreciate your cooperation in advance.

Best regards,

Anastasia Vasileiou

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors, thank you for the opportunity to read your paper. The topic is very interesting. However, improvement are necessary.

Title. The title should be revised to better reflect the content of the article.

Abstract. The scientific value, originality, and contribution to the field of knowledge are not presented.

Introduction. It is common to present the current state of research in the field in order to reveal the existing gap in the literature. Only after presenting what is done by other scholars and what results are obtained analyzing various concepts and relations existing in the field, is possible to demonstrate how the research is going to close the existing gap in the literature. Without a thorough presentation of the state of current research in the field, it is hard to asses the value and originality, also, the pursued contribution of the study.

Theoretical background. Presenting the term “medical tourism”, the authors emphasize the existing ambiguity in the literature: “Health and wellness tourism, commonly referred to as medical tourism” (lines 12-13) and “Some consider medical tourism as part of health tourism, while others emphasize the difference between the two” (lines 89-90). Moreover, neither the term, nor the authors’ position are clearly revealed in the literature analysis. The authors are encouraged to provide the definition of the “medical tourism” (in regard to health and wellness tourism) which would lay a background and understanding for this research.

It is highly recommended to emphasize (maybe to generalize in a table) the main medical services provided in Greece for tourists.

Discussing the medical tourism in Greece, the authors present medical services provided, e.g., plastic surgeries, IVFs, etc. However, while discussing the issue in a framework of Central Macedonia, the authors leave medical tourism aside and analyze health tourism services like SPA.  

The authors use several citation styles for references, thus burdening the reader.

Materials and methods. The research methods are presented clearly; however, they are incomplete. Sample characteristics and sampling procedures should be provided in this part of the paper. Also, the methods used for data analyses should be presented and described.

Results. The authors have chosen to present the research results in tables. First, it is not necessary presenting same result in number and in percentage. Secondly, the authors could have chosen a bit more outstanding method (e.g. cross-tabulations), because currently it doesn’t look informative. Also, as the questionnaire was not constructed based on the analyzed literature, it is hard to assess its suitability to reveal the issue.

Discussion. The discussion part is supposed to discuss the research results comparing them with the results obtained by other scholars. Currently, the discussion has a weak connection to the results obtained, and does not present the contribution to the existing knowledge.

Conclusions. Conclusions are wide and complete.

Comments on the Quality of English Language

Lots of typos and punctuation mistakes can be found.

Author Response

Dear Reviewer 2,

Thank you for providing feedback and granting us the opportunity to publish this article. We have meticulously incorporated your valuable advice into the revised version, with all modifications prominently highlighted in yellow in the revised article. To summarize, the key adjustments made are as follows:

1) Title was changed to include the term 'sustainable'.

2) Tables 8-17 were eliminated, and the text was modified to enhance the article's readability.

3) Research Questions were reformulated and a justification for their selection was made.

4) In order to clarify issues of research methodology, the following chapters have been added to the article

3.3.1. Systematic Literature Review

3.5. Conducting the Quantitative Research

3.6. Analysis of Survey Data

3.7. Reliability and Validity of Research Instrument

5.2. Interconnection between Sustainable Development Goals (SDGs) and SWOT Analysis

5.2.1. Sustainable factors in the context of medical tourism within Central Macedonia / Greece

5.2.2. Negative impact of medical tourism on locals, the environment and SDG’s.

Our responses to your comments are presented in detail below:

*Dear Authors, thank you for the opportunity to read your paper. The topic is very interesting. However, improvement are necessary.

Title. The title should be revised to better reflect the content of the article. Comment 1: please see new title (The title was changed to include the term 'sustainable')

Abstract. The scientific value, originality, and contribution to the field of knowledge are not presented.

Comment 2: The abstract underwent modifications in accordance with your recommendations.

Introduction. It is common to present the current state of research in the field in order to reveal the existing gap in the literature. Only after presenting what is done by other scholars and what results are obtained analyzing various concepts and relations existing in the field, is possible to demonstrate how the research is going to close the existing gap in the literature. Without a thorough presentation of the state of current research in the field, it is hard to asses the value and originality, also, the pursued contribution of the study.

Comment 3 The introduction, the gap in the literature and the current research in the field have been revised in line with your suggestions.

Theoretical background. Presenting the term “medical tourism”, the authors emphasize the existing ambiguity in the literature: “Health and wellness tourism, commonly referred to as medical tourism” (lines 12-13) and “Some consider medical tourism as part of health tourism, while others emphasize the difference between the two” (lines 89-90). Moreover, neither the term, nor the authors’ position are clearly revealed in the literature analysis. The authors are encouraged to provide the definition of the “medical tourism” (in regard to health and wellness tourism) which would lay a background and understanding for this research.

Comment 4: As a reply, we propose this opinion of Hall 2011: ‘Health and medical tourism is a complex area of study… Such research must include contributions not only from medical and health research but also from tourism studies’. (Hall CM. Health and medical tourism: a kill or cure for global public health?. Tourism review. 2011 May 10;66(1/2):4-15.). We have included this reference in the new version of our paper.

 

It is highly recommended to emphasize (maybe to generalize in a table) the main medical services provided in Greece for tourists.

Comment 5: As reply please see chapter 6.2. Insufficient relevant statistics and data in Greece prevent the creation of a specific table..

Discussing the medical tourism in Greece, the authors present medical services provided, e.g., plastic surgeries, IVFs, etc. However, while discussing the issue in a framework of Central Macedonia, the authors leave medical tourism aside and analyze health tourism services like SPA.  

Comment 6: kindly see above, comment 4.

The authors use several citation styles for references, thus burdening the reader.

Comment 7: Some relevant modification have been made.

Materials and methods. The research methods are presented clearly; however, they are incomplete. Sample characteristics and sampling procedures should be provided in this part of the paper. Also, the methods used for data analyses should be presented and described.

Comment 8: The methodology and the findings of the Systematic Literature Review (SLR) underwent modifications in accordance with your recommendations

Results. The authors have chosen to present the research results in tables. First, it is not necessary presenting same result in number and in percentage. Secondly, the authors could have chosen a bit more outstanding method (e.g. cross-tabulations), because currently it doesn’t look informative. Also, as the questionnaire was not constructed based on the analyzed literature, it is hard to assess its suitability to reveal the issue.

Comment 9: Tables 8-17 were eliminated, and the text was modified to enhance the article's readability. Regarding questionnaire structure please see chapter 3.4. (‘To pursue the research objectives, a primary quantitative survey was designed at the visitor level using a structured questionnaire, with a combination of questions from 2 other surveys’).

Discussion. The discussion part is supposed to discuss the research results comparing them with the results obtained by other scholars. Currently, the discussion has a weak connection to the results obtained, and does not present the contribution to the existing knowledge.

Comment 10: The discussion underwent modifications in accordance with your recommendations.

Conclusions. Conclusions are wide and complete. OK no Comment

English Language: Lots of typos and punctuation mistakes can be found.

Comment 11: Numerous adjustments have been implemented concerning the English language.

 

In any case we have highlighted all alterations in the revised paper with the color yellow.

 

We appreciate your cooperation in advance.

Best regards,

Anastasia Vasileiou

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Please elaborate research methodology part and provide a detailed procedure.

 

Please check the research questions and explain how these items were selected.

Comments on the Quality of English Language

English is fine

Author Response

Dear Reviewer 3,

Thank you for providing feedback and granting us the opportunity to publish this article. We have meticulously incorporated your valuable advice into the revised version, with all modifications prominently highlighted in yellow in the revised article. To summarize, the key adjustments made are as follows:

1) Title was changed to include the term 'sustainable'.

2) Tables 8-17 were eliminated, and the text was modified to enhance the article's readability.

3) Research Questions were reformulated and a justification for their selection was made.

4) In order to clarify issues of research methodology, the following chapters have been added to the article

3.3.1. Systematic Literature Review

3.5. Conducting the Quantitative Research

3.6. Analysis of Survey Data

3.7. Reliability and Validity of Research Instrument

5.2. Interconnection between Sustainable Development Goals (SDGs) and SWOT Analysis

5.2.1. Sustainable factors in the context of medical tourism within Central Macedonia / Greece

5.2.2. Negative impact of medical tourism on locals, the environment and SDG’s.

Our responses to your comments are presented in detail below:

 

Please elaborate research methodology part and provide a detailed procedure.

Comment 1: Tables 8-17 were eliminated, and the text was modified to enhance the article's readability. Moreover, the methodology and the findings of the Systematic Literature Review (SLR) underwent modifications in accordance with your recommendations for detailed procedure.

 

Please check the research questions and explain how these items were selected.

Comment 2: Research Questions were reformulated and a justification for their selection was made.

 

 

English Language: English is fine

Comment 3: Numerous adjustments have been implemented concerning the English language.

 

In any case we have highlighted all alterations in the revised paper with the color yellow.

 

We appreciate your cooperation in advance.

Best regards,

Anastasia Vasileiou

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Overall, the comments from reviewers have been adequately addressed. However, with the new material, there is a tendency to be very repetitive, particularly in the findings section where information is repeated for each of the tests conducted. Those sections can be condensed considerably by paraphrasing them. 

The acronym RCM for the Region of Central Macedonia should be introduced after the first mention and then used consistently throughout. What is "intra-border tourism"? Is that the same as domestic tourism? "The SWOT analysis (see Table 8) delves into both the company's internal and external 815 surroundings" - what is this company that is suddenly being analyzed? The study was dealing with  the Region of Central Macedonia. The reference to "The Global Goals and the 2030 Agenda for Sustainable Development" makes little sense. Referring the the UN's 2030 Sustainable Development Goals would be more correct. The same holds true for "the seventeen sustainable development and social sustainability goals established by the United Nations". 

Comments on the Quality of English Language

see above

Author Response

Dear Reviewer 1,

We appreciate your second feedback.

Below, you will find a detailed presentation of our responses to your comments.

Comment 1: ‘…with the new material, there is a tendency to be very repetitive, particularly in the findings section where information is repeated for each of the tests conducted. Those sections can be condensed considerably by paraphrasing them’. Done: we have rephrased these sections.

Comment 2: ‘The acronym RCM for the Region of Central Macedonia should be introduced after the first mention and then used consistently throughout’. Done.

Comment 3: ‘What is "intra-border tourism"? Is that the same as domestic tourism? Yes, indeed. Corrected.

Comment 4: ‘ "The SWOT analysis (see Table 8) delves into both the company's internal and external 815 surroundings…" - what is this company that is suddenly being analyzed?’  Yes, the study was dealing with the RCM. This point has been corrected.

Comment 5: ‘Referring the UN's 2030 Sustainable Development Goals would be more correct’. Done.

Comment 6: ‘Moderate editing of English language required’. We made pertinent corrections using the respective applications in both the initial and subsequent checks. 

Please also note that in the second revision of the paper, all modifications are prominently highlighted in green.

Thank you for your cooperation in advance.

Best regards,

Anastasia Vasileiou

Reviewer 2 Report

Comments and Suggestions for Authors

Improvements look satisfactory.

Author Response

Dear Reviewer 2,

We appreciate your second feedback.

Please note that in the second revision of the paper, all modifications are prominently highlighted in green.

Thank you for your cooperation in advance.

Best regards,

Anastasia Vasileiou